<form action="" method="get">
    <style>.container2 ul.dropdownlist li{list-style:none; }</style>
    <table class="form-table">
        <tbody>
            <input type="hidden" name="s" value="doctor"  />
			<?php foreach($fields as $k=>$v):?>
            <tr valign="top" class="col-3">
                <th scope="row"><label for="blogname"><?php echo $v['label'];?></label></th>
                <td class="block">
                    <?php echo $v['element'];?>
                    <p class="description"><?php echo $v['info'];?></p>
                </td>
            </tr>
            <?php endforeach;?>
            <tr valign="top">
            	<td rowspan="2"><input type="submit" id="submit" class="button button-primary" value="<?php _e('Find a Doctor', THEME_NAME); ?>" /></td>
            </tr>
        </tbody>
    </table>
</form>